SCALE Final Consensus Statement - European Pressure Ulcer ...

If a patient is to be treated as palliative, it should be
stated in the medical record, ideally with a reference
to a family/caregiver meeting, and that consensus
was reached. If specific palliative scales such as the
Palliative Performance Scale, 23 or other palliative
tools were utilized, 24 they should be included in
the medical record. Palliative care must be patientcentered,
with skin and wound care being only a
part of the total plan of care.
It is not reasonable to expect that the medical
record will be an all-inclusive account of the
individual’s care. Charting by exception is an
appropriate method of documentation. This form
of documentation should allow the recording
of unusual findings and pertinent patient risk
factors. Some methods of clinical documentation
are antiquated in light of today’s complexity of
patient care and rapidly changing interprofessional
healthcare environment; many current
documentation systems need to be revised and
streamlined.
Statement 3
Patient centered concerns should be addressed
including pain and activities of daily living.
A comprehensive, individualized plan of care should
not only address the patient’s skin changes and comorbidities,
but any patient concerns that impact
quality of life including psychological and emotional
issues. Research suggests that for wound patients,
health-related quality of life is especially impacted
by pain, change in body image, odors and mobility
issues. It is not uncommon for these factors to
have an effect on aspects of daily living, nutrition,
mobility, psychological factors, sleep patterns and
socialization. 25, 26 Addressing these patient-centered
concerns optimizes activities of daily living and
enhance a patient’s dignity.
A comprehensive, individualized
plan of care should not only address
the patient’s skin changes and comorbidities,
but any patient concerns
that impact quality of life including
psychological and emotional issues.
Statement 4
Skin changes at life’s end are a reflection of
compromised skin (reduced soft tissue perfusion,
decreased tolerance to external insults, and
impaired removal of metabolic wastes).
When a patient experiences SCALE, tolerance
to external insults (such as pressure) decreases
to such an extent that it may become clinically
and logistically impossible to prevent skin
breakdown and the possible invasion of the skin
by microorganisms. Compromised immune
response may also play an important role,
especially with advanced cancer patients and with
the administration of corticosteroids and other
immunosuppressant agents.
Skin changes may develop at life’s end despite
optimal care, as it may be impossible to protect the
skin from environmental insults in its compromised
state. These changes are often related to other
cofactors including aging, co-existing diseases and
drug adverse events. SCALE, by definition occurs at
life’s end, but skin compromise may not be limited
to end of life situations; it may also occur with acute
or chronic illnesses, and in the context of multiple
organ failure that is not limited to the end of life. 8,
27
However, these situations are beyond the scope of
this panel’s goals and objectives.
SCALE Final Consensus Statement, October 1, 2009 Page 7